The contribution of eHealth and mHealth to improving the performance of the health workforce: a review

Abstract

Introduction: eHealth and mHealth are technologies that allow
services to be extended closer to patients, in pursuit of the
objectives of Health 2020: a European policy framework and
strategy for the 21st century and of the Global Strategy on Human
Resources for Health: workforce 2030. As Europe faces increased
demand for health services due to ageing populations, rising
patient mobility, and a diminishing supply of health workers
caused by retirement rates that surpass recruitment rates,
this paper illustrates how eHealth and mHealth can improve
the delivery of services by the health workforce in response to
increasing demands.
Methods: Through a scoping literature review, the impact of
eHealth/mHealth on the health workforce was assessed by
examining how these technologies affect four dimensions of the
performance of health professionals, according to the so-called
AAAQ: availability, accessibility, acceptability, and quality.
Results: Few high-quality studies were found. Most studies
focused on the utilization of text messaging (SMS) for patient
behavior change, and some examined the potential of mhealth
to strengthen health systems. We also found some limited
literature reporting effects on clinical effectiveness, costs, and
patient acceptability; we found none reporting on equity and
safety issues. Facilitators and barriers to the optimal utilization
of eHealth and mHealth were identified and categorized as they
relate to individuals, professional groups, provider organizations,
and the institutional environment.
Discussion: There are ongoing clinical trial protocols of largescale,
multidimensional mHealth interventions, suggesting that
the current limited evidence base will expand in coming years.
The requirement for new digital skills for human resources for
health (HRH) was observed as significant. This has implications
for the education of health workers, the management of health
services, policy-making, and research.

Full text

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INTRODUCTION
e potential contribution of eHealth and mHealth to making health care delivery more eective is broadly
recognized (1). Here we refer to eHealth as the “cost-eective and secure use of information and communication
technologies in support of health and health-related elds, including health care services, health surveillance,
health literature, and health education"; and to mHealth as the “use of mobile and wireless technologies to sup-
port the achievement of health objectives” (1, 41).
In Europe, their use is already extensive in some countries, while their use in the majority has just begun. Among
other requirements, the implementation of eHealth/mHealth-based services depends on the availability of health
professionals, administrative and support sta, and managers with adequate new digital skills (2). Innovations
such as the provision of alerts to patients for therapeutic guidance and for monitoring drug adherence, or digital
support to clinical and administrative tasks, oer the potential of making services more accessible, eective and
POLICY AND PRACTICE
The contribution of eHealth and mHealth to improving the
performance of the health workforce: areview
Luís Velez Lapão1, Gilles Dussault1
1Global H ealth and Tropica l Medicine, Instituto de Higi ene eMedicina Tropical, Universidade Nova de Lisboa, Li sbon, Portu gal
Corresponding author: Luís Velez Lapão (email: luis.lapao@ihmt.unl.pt)
ABSTRACT
Introduction:
eHealth and mHealth are technologies that allow
services to be extended closer to patients, in pursuit of the
objectives of Health 2020: a European policy framework and
strategy for the 21st century and of the Global Strategy on Human
Resources for Health: workforce2030. As Europe faces increased
demand for health services due to ageing populations, rising
patient mobility, and a diminishing supply of health workers
caused by retirement rates that surpass recruitment rates,
this paper illustrates how eHealth and mHealth can improve
the delivery of services by the health workforce in response to
increasing demands.
Methods:
Through a scoping literature review, the impact of
eHealth/mHealth on the health workforce was assessed by
examining how these technologies affect four dimensions of the
performance of health professionals, according to the so-called
AAAQ: availability, accessibility, acceptability, and quality.
Results:
Few high-quality studies were found. Most studies
focused on the utilization of text messaging (SMS) for patient
behavior change, and some examined the potential of mhealth
to strengthen health systems. We also found some limited
literature reporting effects on clinical effectiveness, costs, and
patient acceptability; we found none reporting on equity and
safety issues. Facilitators and barriers to the optimal utilization
of eHealth and mHealth were identied and categorized as they
relate to individuals, professional groups, provider organizations,
and the institutional environment.
Discussion:
There are ongoing clinical trial protocols of large-
scale, multidimensional mHealth interventions, suggesting that
the current limited evidence base will expand in coming years.
The requirement for new digital skills for human resources for
health (HRH) was observed as signicant. This has implications
for the education of health workers, the management of health
services, policy-making, and research.
Keywords: EHEALTH/MHEALTH; HUMAN RESOURCES FOR HEALTH; HEALTH WORKFORCE PERFORMANCE;
DIGITALIZATION OF HEALTH

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THE CONTRIBUTION OF EHEALTH AND MHEALTH TO IMPROVING THE PERFORMANCE OF THE HEALTH
WORKFORCE: AREVIEW
ecient. Such services are expected to benet the users of services, health care professionals, provider organiza-
tions and the entire health care system, in the form of increased safety, quality of services, and eciency gains (3).
However, many obstacles to the implementation of eHealth/mHealth remain (4).
is paper focusses on addressing how eHealth/mHealth can increase the availability, accessibility, acceptability
and quality (AAAQ) of the health workforce (2), and thereby scale-up its capacity to deliver services that are bet-
ter aligned with population needs.
We present examples that illustrate how eHealth and mHealth are used and how they improve performance and
thereby “help improve the lives of European citizens, both patients and health professionals, while tackling the
challenges to health care systems” (5). We also include examples of countries with advanced implementation, and
discuss facilitators and barriers to the optimal utilization of new communication and management technologies
and their implications for the education of health workers, service management, policy-making, and research.
But rst, the general picture of their utilization in Europe is reviewed.
METHODS
A scoping review of literature published in English was performed on the utilization of eHealth/mHealth in Eu-
rope; the search in the PubMed and Google Scholar databases combined the following terms: Human Resources
for Health, eHealth, mHealth, healthcare service delivery, and digital skills.
e example of two so-called digitally advanced countries, identied as such by the European momentum for
mainstreaming telemedicine deployment in daily practice (MOMENTUM), aplatform where clinicians share their
experience in deploying telemedicine services into routine care (6), was used. ese are Norway, as this country’s
geography led to the necessity of deploying ehealth to address health coverage issues; and Portugal, a small
country with anational centralized ehealth system. e examples were documented in detail to draw lessons on
what enables or impedes the optimal utilization of ehealth/mhealth technologies, and on changes observed in the
performance of the health workforce. e literature review and the country examples were analyzed according to
the AAAQ dimensions. is in turn helped identify the impact of ehealth/mhealth on the education and manage-
ment of health workers and on related policy and research.
RESULTS
e literature review identied several examples of using eHealth and mHealth technologies in the process of
the digitalization of health care services, including support for electronic health records, electronic prescription
and Internet-of-ings (equipping patients’ home with sensors to monitor and transfer health data), and big data/
articial intelligence (7).
Most studies focused narrowly on text messaging systems for patient behavior change, and afew studies examined
systems for strengthening aspects of eHealth/mHealth (8). ere was limited literature on clinical eectiveness,
costs, and patient acceptability, and none on equity and safety issues. In addition, there were only four papers
on eHealth/mHealth and digital skills requirements for health professionals (9–12). Despite the bold promise of
eHealth/mHealth to improve health care, much remains unknown about whether and how this will be fullled.
We identied registered clinical trial protocols of large-scale, multidimensional eHealth/mHealth interventions,
suggesting that the current limited evidence base will expand in the coming years.
e results are presented in three par ts: eHealth/mHealth in Europe, case studies of Norway and Portugal, and the
impact on the performance of the health workforce and conditions for successful implementation and utilization.

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THE CONTRIBUTION OF EHEALTH AND MHEALTH TO IMPROVING THE PERFORMANCE OF THE HEALTH
WORKFORCE: AREVIEW
EHEALTH AND MHEALTH IN THE EUROPEAN REGION
e literature suggests that eHealth/mHealth can be used as tools to meet the challenges of healthy ageing and
universal and equitable access to health services in the context of the increasing burden of chronic diseases (13).
More specically, eHealth/mHealth has showed capacity to:
• improve access to awide range of services at all levels of health care– primary, secondary and tertiary– cover-
ing conditions such as mental illness, heart and cerebrovascular disease, diabetes, cancer and trauma. Services
such as radiology, pathology and rehabilitation have also beneted (14 , 15);
• promote individualized, patient-centered care at alower cost (16, 17) ;
• enhance eciency in clinical decision-making and prescribing, through easier communication between health
care providers (14);
• increase the eectiveness of chronic disease management in both long-term care facilities and at home (14);
• promote the adoption of healthy lifestyles and self-care (18).
As of 2008, the European Commission adopted a policy to encourage the development of telemedicine (5). It
identied the ways in which telemedicine services might assist patients, particularly those living in remote areas
or experiencing conditions that might not be treated as easily or as oen as needed. It also cited specic benets,
such as: improving access to health care by giving access to specialists who are not available locally, and; at the
organizational level, helping to shorten patient waiting lists, to optimize the use of resources and enable produc-
tivity gains.
In the last decade, anumber of European, national and regional initiatives have been launched in support of
the development of eHealth/mHealth under the Competitiveness and Innovation Programme– in particular its
Policy Support Programme (19), and its pilot experiments or European FP7 projects such as Renewing Health (20),
United4Health (21), and Digital Agenda for Europe (22). Major policy documents, such as Horizon 2020 (23), the
European Innovation Partnership (EIP) and its rst partnership on Active and Healthy Ageing (AHA) (24), the
2012 European eHealth Action Plan (5), and the New Health Technologies: Managing Access, Value and Sustain-
ability (25), have highlighted the value of using technologies, such as eHealth/mHealth, in health care. e 2008
European Health Telematics Association (EHTEL) brief, Sustainable Telemedicine: paradigms for future-proof
healthcare, proposed good practices in the use of ICT in integrated care (6). e deployment of eHealth/mHealth
is already the objective of several European initiatives (see Box 1).

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BOX 1: EHEALTH/MHEALTH INITIATIVES AND ACTIONS IN THE EUROPEAN REGION
• European Momentum for Mainstreaming Telemedicine Deployment in Daily Practice (http://www.telemedicine-
momentum.eu/) (2012–15)
• European Innovation Partnership on Active and Healthy Ageing (https://ec.europa.eu/eip/ageing/home_en) (2014–20)
• Discussion Paper: Filling the Gap: Legal and Regulatory Challenges of Mobile Health (mHealth) in Europe (ITU, 2014)
• EU Green Paper (2014) on the potential of mHealth for health care services
• EU project DECIPHER PCP, to create amobile health care platform which would enable secure cross-border access to
existing patient health care portals. (www.decipherpcp.eu) (2013–17)
• Renewing Health: aimed at implementing large‐scale, real-life testbeds for the validation and subsequent evaluation
of innovative eHealth/mHealth services for the remote monitoring and treatment of chronic patients suffering from
diabetes, chronic obstructive pulmonary disease or cardiovascular diseases. Nine regions from different European
countries participate: Regione Veneto (Italy), Region Syddanmark (Denmark– Coordinator), Northern Norway Regional
Health Authority (Norway), South Karelia Social and Health Care District (Finland), County Council of Norrbotten
(Sweden), Catalunya (Spain), Region of Central Greece, Carinthia (Austria), and Land of Berlin (Germany). (2011–14)
• Centre for Telemedicine and Telehealthcare, 2012, Central Denmark Region (http://www.smartaarhus.eu/projects/
centre-telemedicine-and-telehealthcare).
• An implementation resource that focuses on coaching, monitoring and consultations for people with long-term
conditions, developed by the University of York to address innovation in long-term care (26).
• A toolkit that provides astructured approach to delivering the business objectives of eHealth/mHealth, developed to
support the UK’s National Health Service challenge to leverage the use of mHealth (27).
• A collection of eHealth/mHealth case studies (http://www.cocir.org/leadmin/ Publications_2011/telemedicine_
toolkit_link2.pdf)(28).
• A collection of eHealth/mHealth testimonials collected by the campaign for eHealth/mHealth in support of integrated
care, a2011 initiative of Brussels-based organizations (http://telemedicine-momentum.eu/testimonials/) (29, 32).
Currently, eHealth/mHealth exists through three main types of services: diagnosis, monitoring and consultation:
• Diagnosis: The results of x-ray, ultrasound, CT, MRI, ECG or Holter exams are sent digitally from adiagnostic device
to the appropriate health professionals who in turn make adiagnosis that is sent digitally to the referring physician or
diagnostic clinic.
• Monitoring: Data derived from eHealth/mHealth devices measuring patient vital signs are tracked by a monitoring
centre, individual clinician or website. Typically, the recipient of the data uses clinical guidelines to identify any deviation
from what is considered normal for that patient. Embedded algorithms, written guidelines or professional judgment all
support this process. If an unusual event occurs, the monitoring process generates aresponse in the form of an alert,
contact with aclinician, or some form of online guidance to the patient.
• Consultation: When avirtual visit or dialogue takes place instead of, or in addition to, aface-to-face encounter.
TWO EXAMPLES OF UTILIZATION OF EHEALTH/MHEALTH IN NORWAY
ANDPORTUGAL
NORWAY
e Electronic platform for integrated home care of long lasting and chronic ulcers at the University of North Nor-
way Hospital (UNN: http://www.telemedicine-momentum.eu/ulcers-no/) aims to facilitate cooperation between
the patient, out-patient clinic at the hospital, patient’s general practitioner, and home care personnel. e platform
is aweb-based electronic health record available via the Internet that can be used from computers, mobile phones
and tablets. It is possible to register digital images of ulcers, compare images over time, ask for advice, and discuss
the most appropriate treatment. is service is expected to lead to better care, better quality of life for the patient,
and more eective treatment. It is expected that the number of hospital visits will be reduced along with resulting
cost-savings. It also leads to the upgrading of ulcer treatment skills among involved home care personnel.

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e service covers patients with chronic conditions and those undergoing aspecic treatment. Up to ten people
receive the service each month. is service oers diagnosis, mobile access to information, monitoring, therapy
and treatment. Local health personnel as well as the patient can send images and questions electronically to the
hospital, receive answers, and discuss dierent options for action.
PORTUGAL
For every 1000 newborns worldwide, eight contract some type of cardiopathy (29, 30). For children delivered in
District Hospitals, telemedicine allows for arapid and valid diagnosis of complex paediatric cardiopathies and
for an adapted follow-up.
e Hospital Pediátrico de Coimbra (HPC) is a95-bed hospital that serves central Portugal and apopulation of
2.3 million representing about 25% of the total population of the country. In October 1998, HPC launched Medi-
graf, an eHealth system for teleconsultation that enables the reading of an eco-cardiogram in real-time at adis-
tance, for example, in district hospitals (29). It is also possible to communicate by telephone with aphysician–
usually apaediatrician– based at HPC, in order to make acomplete distance examination. Images and sounds
can be recorded in the system database and made available at both ends. In practice, the project experienced some
barriers, such as in communicating the objectives of the telemedicine service, being seen as anon-user-friendly
technology, not being clear regarding the remuneration of consultations, and insucient training. Leaders of the
project promoted the participation of physicians in apilot experiment and invited other regional hospitals to join
the task force responsible for the development of the experiment at HPC. Workshops to train physicians in the use
of telemedicine were conducted and helped raise their interest in the project.
IMPACT OF EHEALTH/MHEALTH ON THE PERFORMANCE OF THE HEALTH
WORKFORCE
Literature remains scarce about how these new services aect the health workforce: here we examine what the
literature says about the AAAQ dimensions of the health workforce:
Availability: e more general literature indicates that the utilization of eHealth/mHealth augments
the productivity of clinicians thanks to time-saving practices, less paper work and more rapid access to
information. Higher productivity translates into increased availability and capacity to provide services to
more users, even if the absolute numbers of health professionals remain constant (8, 9, 28, 29, 31, 33, 34).
Accessibility: Accessibility improves as providers intervene at a distance, with the capacity to diagnose
problems and monitor patient conditions through mobile devices (14, 3 0 , 31). Specialists, who typically
concentrate in urban areas and higher-complexity clinics and hospitals, become accessible as they interact
with their colleagues in general practice or directly with patients, irrespective of distance. is has the
potential to facilitate the development of home care as well as the integration of services (10, 12, 18, 29, 35).
Acceptability: eHealth/mHealth services make communication with patients easier, and more direct and
adapted to each individual needs, thereby potentially enhancing the acceptability of providers. is is more
likely with younger persons who are more familiar with the utilization of computers and mobile devices;
strategies to facilitate their use by older patients may therefore be needed (14, 28, 36).
Quality: Finally, eHealth and mHealth tools give providers rapid access to valid information, second opinions
and guidelines, all of which contribute to scaling-up the competencies and compliance with professional
standards, and thereby improving patient safety and service eectiveness (7, 10, 18, 28, 30).
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DISCUSSION
Online services are already changing how many sectors of the economy function, but they are relatively new in
health care. is raises questions about what can facilitate their utilization, and which barriers need to be over-
come to make real the potential performance gains of health workers and health services. eHealth/mHealth is
not apanacea, but it oers signicant opportunities to improve access to care, contain costs and scale-up quality.
Facilitators and barriers have been identied in relation to: individuals, such as patients, providers and managers;
professional associations; provider organizations; and the institutional and regulatory environment. e acquisi-
tion or development of digital skills by health workers is critical. is has implications for the education of health
workers, the management of health services, policy-making and research. Proper eHealth service implementation
requires adjustments in service delivery and in how work is organized (37–38).
Competencies to work in adigitalized environment have already been identied as among the core competencies
which health professionals must have to deliver the services that meet the current and future needs of populations
(39, 4 0). e policy challenge here is for educational institutions to adapt the contents of curricula and learning
strategies to prepare future professionals for transformed ways of practicing; it also includes the need to help the
existing workforce acquire digital skills which did not exist when they were initially educated. Curricular changes
are notoriously long to make as they imply the review of accreditation norms, retraining of teaching sta or the
introduction of new mechanisms to evaluate competencies.
e impact of eHealth/mHealth on the provision of services will aect the availability of the health workforce
dierently, depending on the type of service. In some instances, it may lead to areduction of needs if productivity
increases and demand remains constant. More likely, it will generate additional and new needs. For instance, as
these tools enable reaching out to populations previously without access to some categories of health workers–
such as medical specialists, physiotherapists and psychologists– the demand for the services of these profession-
als will increase. Also, as professionals are now able to monitor patients remotely, more physicians, nurses and
pharmacists will be needed to respond to ademand in rapid growth from apopulation of patients with one, and
oen more than one, chronic condition. New categories of professionals in telenursing, telepharmacy, health data
analysis, and most probably in other areas and functions which are not yet known, will also be needed.
e facilitators and barriers to the diusion of eHealth/mHealth are not very dierent from that of other inno-
vations. eir adoption as routine tools by health workers and provider organizations will be facilitated by the
favorable cost-benet ratio of their utilization. As costs continuously drop, the power and potential of these tools
will rise. Also, the new generations of health workers born into arapidly digitalized environment are less likely
to resist adopting these tools; on the contrary, it can even be expected that they will contribute to their further
development. Factors such as engaging stakeholders in implementing change, the visibility of its advantages and
user-friendliness, the leadership of respected so-called champions, access to training, the commitment and sup-
port of managers and decision-makers, good planning, and an enabling nancial and legal environment can all
play apositive role (41). eir absence can constitute barriers, but in the case of eHealth/mHealth, the risks of
barriers being stronger than facilitators are reduced. For instance, atypical barrier such as the resistance of older
workers becomes less of an issue as the new tools become more user-friendly and as their utility for the worker,
patient and organization is almost immediately apparent.
e technology is changing more rapidly than the organizational and institutional environment. Issues linked
to legal responsibility, the denition of scopes of practice, remuneration and reimbursement, and the standard-
ization of tools are starting to be addressed (6, 32, 42). ese are particularly dicult in acontext such as that
of the European Union where the mobility of health workers and patients is afundamental right. Another issue
relates to planning the future health workforce in acontext of rapid technological, demographic, epidemiological,
economic and social change.
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ere are two principal limitations to this article. First, it only covers publications in English. It does not include
publications in French, Portuguese, Russian or Spanish that report experiences of the utilization of eHealth/
mHealth in countries where these languages are used, although researchers tend to publish in English to reach
out to a broader audience. e second, more important, limitation is that the literature reviewed does not include
studies that report experiences evaluated according to a rigorous research protocol. Information on the results
of experiences is based primarily on administrative evaluations and on assessments by providers and patients.
CONCLUSION
It is aparadox that the uptake of eHealth/mHealth services is more advanced in some low-income countries than
in more economically developed one. is is changing rapidly as numerous initiatives to promote and facilitate
their use have been launched and as some countries are becoming good models of integration for new commu-
nication technologies. e challenge remains to move from the recognition of the potential benets of eHealth/
mHealth to their actual utilization on alarge scale, in aroutine manner. In the European context, there seems to
be more facilitators than barriers which bodes well for the future of health services in terms of improved accessi-
bility, eectiveness and eciency. It also oers the potential for better working conditions and higher satisfaction
for health workers as they will be better equipped to do their job.
e benets of eHealth/mHealth will not come spontaneously. An enabling policy environment is aprerequisite,
as is the case for any major change. Research can help inform the policy process if it is well targeted and if its re-
sults are communicated to policy-makers in away that encourages and supports their utilization. Policy-makers
will be interested in the economics of the utilization of eHealth/mHealth; direct costs may be low and there may
be savings from less visits and hospitalizations, but indirect costs also need to be assessed, whether it is for train-
ing or through increased demand induced by the greater accessibility facilitated by the technologies. Research
on the process of implementation of eHealth/mHealth-based services is also important, including cross-national
comparisons and studies. Another topic for research, more complex to study but most relevant, is their impact on
health outcomes.
Acknowledgements: None declared.
Sources of fund ing: is work was supported in part by the Portuguese Fundação pa ra aCiência ea Tecnologia
(FCT) funds (UID/Multi/04413/2013).
Conicts of interest: None declared.
Disclaimer: e authors alone are responsible for the views expressed in this publication and they do not
necessarily represent the decisions or policies of the World Health Organization.
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